Interventional Radiology

femoral vein thrombolysis case study

- 55 year old male with severe pain, swelling, and redness in thigh - severe DVT and superficial phlebitis; PE - pt. put on heparin - IVC filter placement and thrombolysis of DVT was requested

tunneled dialysis catheter

- IR usually used IJ due to less risk - older surgeons usually use subclavian (can pinch catheter, can clip lung apex, can cause arm artery collapse)

percutaneous trans hepatic cholangiogram (PCT) with drainage

- PTC or biliary drainage - used to treat obstructive jaundice caused by tumors, benign strictures, or stones

catheter directed PE lysis

- TPA: heavy duty clot buster; patient must go to ICU because it can cause bleeding elsewhere - CTA: gold standard for PE signs of heart strain: - tachycardia - bowing septum - BP changes

venous insufficiency

- backward flow of flood in vein due to faulty valves - in legs, causes bulging varicose veins, pain/heaviness/aching/itching/restlessness and chronic skin changes that lead to ulcers - easily treated via ablation and sclero

CT and MR angiography

- balloon opening of a narrowing - noninvasive visualization of vessels via contract injection into peripheral IV and precise timing of image acquisition by CT or MRI - enables 3D and multiplaner reconstructions - initial workup or trauma and vascular disease

power port

- can have certain catheters and ports for years; can be removed - power injectable lines: can be used for CT and MRI --- rapid injection not all ports can handle --- usually say CT on port - can fracture, kink, or fibrin sheath

venous thrombolysis

- catheter directed infusion of thrombolytics directly into a clot within a large central vein or use of mechanical device inserted intravascularly to break up the clot - important adjunct therapy to traditional treatment of venous thrombosis (anticoagulation) - can be used in central/peripheral veins and dialysis fistulae/grafts

venous access

- central venous access (PICCs: peripherally inserted central venous catheters, central lines, etc.) for long term IV medication (antibiotics, chemotherapy, TPN) - dialysis catheters: via internal jugular or femoral veins, trans hepatic or transcaval - temporary (non tunneled) or permanent (tunneled) - mediport "ports" catheters: via internal jugular vein, tunneled under skin to port inserted in the chest wall

GB drainage

- cystic duct blocked and bile cannot drain from GC - percutaneous GF drainage to place tube and drain bile externally - tube can be places for 6-8 weeks or can be a permanent tube depending on gallbladder response to tube

seroma and abscess drainages

- drainages performed under ultrasound or CT guidance - patients return every 1-3 weeks - removed once 24 hr output is less than ~10 cc

angiography interventions

- embolization (coils or sclerotic agents) - for active bleeding or aneurysms - balloon angioplasty - stent placement - declotting

splenic artery embolization

- hypersplenism due to myelofibrosis --- leads to very low platelet counts which will rebound after splenectomy - splenectomy was scheduled and preoperative embolization was requested to shrink size or decrease blood loss during surgery

IVC filters & indications

- important for preventing migration of lower extremity deep venous thrombus to the pulmonary arteries (pulmonary embolism) - should be removed within 1 year; becomes very difficult to get out, can fracture and migrate - placed through IJ or groin - preferred placement below renal veins (L1-L2 range) indications: - patient's with DVT whom can't be anticoagulated - patient's with breakthrough PE while on anticoagulation

venous ports

- indicated when repeated access to venous is required - medication infusion (chemotherapy), IV fluid, blood draws, parenteral nutrition

facet blocks

- injection into facet joint or small nerves around the joint - used to treat severe to moderate degenerative arthritis - limited to 3 years because of corticosteroid

SVC syndrome

- narrowing of SVC is demonstrated on venogram - blood can't get from head/neck/arms and can be emergent - carinal mass and face and upper extremity edema

basic tools of interventional radiology

- needles - guidewires - catheters - contrast - iodine based contrast; CO2 - imaging equipment - x-ray, ultrasound, CT, MRI

spinal injections

- nevre blocks or blocks - a combination of a long-lasting steroid and a local anesthetic are injected --- steroid: depomedrol or kenalog --- anesthesia: bupivcaine - 3 types: epidural steroid injection, facet block, elective nerve root injection - also done by pain docs and anesthesiologists - not permanent, pain relief/meds wear off in weeks/months

what is IR?

- non-surgical - minimally invasive - image-guided - procedures

chest tube facts

- often removed once output is not purulent and 24 hour output totals are below 100 cc - is pleural effusion located or infected, often treat pleural space with tPa (alteplace) and Dnase to break up junk and get thinks draining - trapping lung = stuck down lung that won't reexpand; kung will always be recollecting fluid in pleural space unless surgical intervention (VATS)

angioplasty and stenting

- opening of narrowed or blocked regions in arteries or veins - uses small balloons inserted over a wire and/or place small stents that hold open the narrowed zone - stents are self-expanding or ballon-expanding, covered or uncovered - large stent grafts are often placed endovascularly in the aorta to treat aortic aneurysms

vertebroplasty

- pain treatment for vertebral compensation fractures - injection of cement into vertebrae under image-guidance to stabilize the bone, prevent height loss, and relieve pain - outpatient procedure, conscious sedation, almost immediate relief, minimal complications - minimally invasive treatment for vertebral compression fractures --- osteoporosis --- malignant disease (MM) - treats pain from height loss

tubes, tubes, and more tubes

- percutaneous transhepatic cholangiogram with drainage - gallbladder drains - nephrostomy tubes - chest tubes - pleurx/aspira catheters - abscess and seromas drainages --- patients followed up in our department periodically to evaluate tubes for position, working properly, or removal

pleurx/aspira catheters

- placed for management of rapidly recurring ascites or pleural effusions - catheter is tunneled and has a cuff - patient can drain fluid at home rather than making frequent trips to the hospital for a para or thoracentesis

transjugular intrahepatic portosystemic shunts (TIPS)

- pressure in the portal vein increased with liver disease; this can cause symptoms (varies that are prone to bleeding, ascites) - decompression of portal venous hypertension by creating a channel between the portal vein and hepatic vein (systemic venous circulation) - via IJ access, sheath is placed within the hepatic vein, TIPS needle used to puncture the portal vein, stents placed along tract

image-guided biopsies and drainages

- previously to access organs and other targets within the body, open surgery was the only option - image-guidance allows placement of biopsy needs or drainage catheters into targets via small skin nicks - CT, US, MRI, or fluoroscopy is used to visualize needle and guide its placement into target - no need for vernal anesthesia, procedure is much faster and minimizes complications - most are done with moderate sedation or local anesthesia on

uterine fibroid embolization

- prior standard for treating uterine fibroids has been surgery: removal of fibroids vs hysterectomy - recent research demonstrates UFE as effective as myomectomy for fibroid treatment - micro catheter inserted into uterine artery with injection of tiny embolization particles that blocks blood supply to fibroid, devasculariing and shrinking it over time - less invasive, shorter hospital stay, only moderate sedation, cost saving, less complications

thoracentesis

- removal of pleural fluid from around the lung (not removal of fluid from within the lung) - seen commonly in patients with pneumonia, empyema, CHF, recent chest or abdominal surgery

contraindications of TIPS

- right sided heart failire - low meids score - history of encephalopathy

thrombectomy/declotting - angioject or "possis"

- saline jets travel backwards at high speed to create a negative pressure zone causing a powerful vacuum effect - thrombus is drawn into the catheter where it is fragmented by the jets or evacuated from the body

embolization

- selective catheterization of a bleeding vessel or abnormal arterial structure with placement of an agent that produces vessel occlusion - not just to stop bleeding; concept can be used to block the blood supply to tumors and starve them to death indications: - arterial bleeds - abnormal arterio-venous connections - block tumor vascular supply

yttrium-90 liver brachytherapy (Y-90)

- small microspheres containing Yttrium-90 are delivered directly into the hepatic artery and will lodge in capillaries of liver - embolism and emit beta radiation (limited range of 1 cm in soft tissue) and cause cell death (preferably of cancer cells mostly)

interventional oncology

- treatment of tumors directly using image-guided percutaneous or endovascular approach - cryoablation/radiofrequency ablation: freezing or heating tumor tissue using specially designed probes inserted directly into the lesion (US, CT, or MR guidance) - chemoembolization (TACE)/radioembolization (Y-90): injection of embolization particles coated with chemotherapy or radiation therapy agents directly into the vessels supplying a tumor

used of IR

- vascular access - drainage catheter placement - chest tubes - stent grafts - angioplasty - gastric/biliary/renal tubes

vascular procedures

- vascular catheters: accessing peripheral and central vessels - fistulograms (dialysis graft declottings) - angiography: including stenting, embolization, declotting, and angioplasty - TIPS: transjugular intrahepatic portosystemic shunt - IVC filters: placement ands retrieval

neurology procedures

- vertebroplasty/kyphoplasty - nerve blocks - discograms

catheter angiography

- visualization of vessels via direct contract injection into catheterized artery or vein - root of IR - creates a roadmap

what do you see?

a chest tube

seroma

collection of serous fluid - large fluid collection across anterior abdomen

fistulograms

dialysis graft declotting - with dialysis, blood is withdrawn from an artery or vein, purified, and returned to a vein

abscess

drain infected fluid - image shoes patient with perforated terminal ileum due to diverticulitis; surgery one week prior to abscess drainage to repair perforation

what are stents used for?

for occlusion or stenosis - come coated in medication

where are long term vascular access for dialysis primarily placed?

in IJ vein with tip advanced to cabal-atrial junction or into right atrium - many of the procedures we do are performed using conscious sedation - RN monitors patient and used fentanyl for pain and versed to help them relax

power PICC

peripherally inserted central catheter - single or dual lumen - cephalic, basilic, or brachial vein - short-term use - commonly placed by PICC nurses or PICC team

powerlines

placed for long term (6 months to a year) antibiotics, chemotherapy, blood draws, etc. - have a cuff

who invented the basis for nearly all minimally invasive procedures in modern medicine?

seldinger technique

hepatic chemoembolization (TACE)

transcatheter arterial chemoembolization - used in palliative treatment of unresectable hepatocellular cancer - life span can be extended 1-2 years - standard treatment: surgery, 60%, 5 year survival - involves puncturing femoral artery and pass catheter through aorta, through the celiac axis and common hepatic artery, and into the artery that supplies the liver - benefits: focused chemotherapy and embolization

mechanical venous thrombectomy

use flow to break up clot or suck it out

balloon angioplasty

various sizes - 2 mm x 2 cm up to 18 mm x 10 cm